Sentinel Event

Sentinel events occur in nearly all health care organizations. According to the Maine Department of Human Services,

facilities that are vigilant about identifying and reporting errorsfoster an organizational culture where staff members feel comfortable reporting patient safety concerns without fear of reprisal. Healthcare facilities that embrace this safety-focused culture look at adverse events as opportunities to learn and improve. (2018, p. 5)

You are assigned a sentinel event topic based on the first initial of your last name (see table below). Based on your assigned topic, research a sentinel event, or create your own scenario. You will use this sentinel event for other assignments later in class.

From a health care provider perspective (e.g., hospital, physicians practice, long-term care, hospice, home health, surgery center, etc.), write a brief description of the sentinel event in your own words.

In addition, address the following:

• Identify the sentinel event, who was involved, what occurred, and where it occurred.
• Describe the applicable accrediting agencys requirements for reporting the event (e.g., OSHA, ACHA, CMS, CDC, CLIA, The Joint Commission [TJC], AHCA, state agencies).
• Discuss the probable cause that may have contributed to the sentinel event (e.g., process failure, human error, policy error, systems error, technology failure, etc.).
• Create a recommendation that will reduce the risk of future events from occurring.